Diagnosis and management of cardiopulmonary events in very low birth weight infants close to discharge: a quality improvement initiative.

BACKGROUND: Cardiopulmonary events (CPE) have a central, obstructive, or mixed etiology. Lack of standardized diagnosis and management of CPE may prolong the length of stay (LOS). OBJECTIVE: To increase the accuracy of CPE diagnosis and decrease LOS by 10% for preterm infants over a 12-month period. METHODS: Develop an evidence-based algorithm to identify type of CPE, determine management approach, and evaluate cardio-respiratory monitors output. Apply model for improvement and statistical process control charts to determine special cause variation. RESULTS: Identification of central apnea increased from 15 to 39% (p < 0.01). LOS decreased 26% from 52.6 days to 39.2 days, with an estimated cost savings of $13,119 per each of the 225 infants in the initiative. CONCLUSION: After implementing an evidence-based algorithm for management of neonatal CPE, a significant increase in the accuracy of the diagnosis of central apnea and cost savings associated with a decrease in LOS were observed.

Fifteen-minute consultation: Cardiac murmurs in the Newborn Infant Physical Examination (NIPE).

The finding of a cardiac murmur on the initial newborn examination is common but may be a source of anxiety for practitioners due to worries about missing critical congenital heart defects (CHDs). This article aims to provide an approach to this common finding, in particular, reviewing the evidence base behind features of the history, examination and subsequent non-specialist investigations which may increase the likelihood of CHDs. The aim of this structured approach is to give clinicians confidence in dealing with this common clinical finding, to be able to pick out those infants most at risk of having critical CHDs.

Exercise in cirrhosis: Translating evidence and experience to practice.

Physical inactivity, sarcopenia, and frailty are highly prevalent, independent predictors of morbidity and mortality in patients with cirrhosis. Across a range of chronic diseases, exercise training is a key recommendation supported by guidelines and, for some conditions, even by governmental funding of exercise programmes. Consistent with the broader chronic disease literature, the evidence for a benefit of exercise in cirrhosis is promising. Several small trials have reported significant improvements in muscle health (mass, strength, functional capacity), quality of life, fatigue, and reductions in the hepatic venous pressure gradient, without adverse events. With strong emerging evidence surrounding the substantial risks of sarcopenia/frailty and our first-hand experiences with liver pre-transplant exercise programmes, we contend that routine patient care in cirrhosis should include an exercise prescription. Some clinicians may lack the resources and necessary background to translate the existing evidence into a practicable intervention. Our team, comprised of physiotherapists, exercise physiologists, hepatologists, transplant specialists, and knowledge translation experts from six North American centres, has distilled the essential background information, tools, and practices into a set of information ready for immediate implementation into clinics ranging from a family practice setting to specialty cirrhosis clinics. Augmenting the rationale and evidence are supplementary materials including video and downloadable materials for both patients and the physician. Supporting the exercising patient is a section regarding information about nutrition, providing practical tips suitable for all patients with cirrhosis.

Enduring neurobehavioral effects of early life trauma mediated through learning and corticosterone suppression.

Early life trauma alters later life emotions, including fear. To better understand mediating mechanisms, we subjected pups to either predictable or unpredictable trauma, in the form of paired or unpaired odor-0.5 mA shock conditioning which, during a sensitive period, produces an odor preference and no learning respectively. Fear conditioning and its neural correlates were then assessed after the sensitive period at postnatal day (PN)13 or in adulthood, ages when amygdala-dependent fear occurs. Our results revealed that paired odor-shock conditioning starting during the sensitive period (PN8-12) blocked fear conditioning in older infants (PN13) and pups continued to express olfactory bulb-dependent odor preference learning. This PN13 fear learning inhibition was also associated with suppression of shock-induced corticosterone, although the age appropriate amygdala-dependent fear learning was reinstated with systemic corticosterone (3 mg/kg) during conditioning. On the other hand, sensitive period odor-shock conditioning did not prevent adult fear conditioning, although freezing, amygdala and hippocampal 2-DG uptake and corticosterone levels were attenuated compared to adult conditioning without infant conditioning. Normal levels of freezing, amygdala and hippocampal 2-DG uptake were induced with systemic corticosterone (5 mg/kg) during adult conditioning. These results suggest that the contingency of early life trauma mediates at least some effects of early life stress through learning and suppression of corticosterone levels. However, developmental differences between infants and adults are expressed with PN13 infants' learning consistent with the original learned preference, while adult conditioning overrides the original learned preference with attenuated amygdala-dependent fear learning.

Genodermatoses with malignant potential.

PURPOSE OF REVIEW: The delineation of syndromes carrying a predisposition to malignancy has led to great insights into the molecular biology of malignancy. Many such syndromes have cutaneous findings which can precede the development of neoplasia. Early recognition of the cutaneous stigmata of the genodermatoses with malignant potential can lead to early diagnosis and initiation of proper screening and treatment when indicated. RECENT FINDINGS: This article reviews 'classic' genodermatoses with malignant potential and highlights recent recommendations for screening and treatment. Additionally more recently delineated syndromes and their cutaneous findings are discussed. SUMMARY: Certain inherited syndromes with a risk of neoplasia exhibit characteristic cutaneous findings. Recognition of these findings by the astute practitioner can lead to early intervention which can impact the course of these rare diseases.

The art of tattooing and the science of tattoo removal.

In recent years there has been a dramatic increase in body tattooing among all socioeconomic groups. This paper describes the techniques of tattooing, the public health implications, methods for removal of tattoos.